2009: The Year in Review

In 2009, primary care and family physicians garnered the attention of the nation as health care reform efforts and the influenza A (H1N1) virus vied for headlines across the country.

Health care reform was the big news of the day in Washington, and the AAFP, along with the other major primary care physician organizations, had a seat at the table and in the Oval Office for the debate. The overarching message: Simply expanding insurance coverage won't meet the goals of health care reform unless the pipeline for primary care physicians improves.

The H1N1 virus also had a big impact on family physicians. Despite being on the front line of health care for the United States, FPs and other primary care physicians initially were left scratching their heads about how H1N1 vaccine was going to be distributed as the country dealt with an influenza pandemic of uncertain severity.

Luckily, H1N1 did not turn out to be the horrific scourge that many had feared. Although more than 12,000 people have died worldwide, it could have been much worse. The extent of the pandemic, however, ferreted out holes in the public health safety net, including gaps in vaccine manufacturing and distribution processes that federal officials now realize they will have to deal with before a bigger and meaner pandemic comes along.

2009 ushered in the arrival of a new administration in the White House. President Obama made national health care reform a major part of his campaign platform, and he moved quickly to align the Democratic majority in Congress behind that lofty goal.

The AAFP worked hard to ensure it had a place at the table during reform discussions. Repeated trips to Capitol Hill by Academy leaders paid off as the AAFP's advice on the benefits of the patient-centered medical home, or PCMH, was sought by legislators tackling the process of writing bills to address the deficiencies of the current health care system, including a purported 47 million uninsured U.S. residents.

The Academy's message also was heard as the administration worked on a stimulus package to help free up a moribund American economy. The final American Recovery and Reinvestment Act, or ARRA, provides $19 billion for health information technology, or health IT; $500 million in additional funding for health care workforce programs, including primary care training grants; and $1.1 billion for comparative clinical effectiveness research to help guide physician practices.

"The stimulus package demonstrates that the Obama administration and Congress believe that primary care and the patient-centered medical home are part of the answer to America's future health care system," said (then) AAFP President Ted Epperly, M.D., of Boise, Idaho.

Welcome as the stimulus package provisions might have been, however, there still was a long way to go in the battle to change how health care is paid for and delivered in the United States. Some analysts pointed out that the PCMH was the necessary foundation for any broad attempts at health care reform.

"A large and growing number of people recognize that the key to health care reform in the long run is turbocharging primary care, said Len Nichols, Ph.D., director of the health care policy program for the New America Foundation. And, indeed, the message seemed to be sinking in as more federal and state politicians, corporate bigwigs, and even everyday consumers picked up on the message of reform incorporated in the PCMH model.

A big part of using the PCMH model as the foundation of health care reform, however, is the issue of payment reform. According to Kevin Grumbach, M.D., professor and chair of the department of family and community medicine at the University of California, San Francisco, the traditional model of primary care has not been very well supported by payers, purchasers or government agencies, so people are turning away from it. "(Sub)specialists have done awfully well in the current environment," he noted, "and there is going to have to be some rebalancing."

That seemed to be a message the Obama administration was exploring, as well. In fact, during comments at the annual meeting of the AMA House of Delegates in June, Obama indicated that the United States needs to make a greater investment in primary care by changing the current physician payment system.

The topic of physician payments led to vigorous debate during the meeting, but in the end, the AMA reaffirmed its support for the PCMH and came out for beefed-up Medicare incentive payments to primary care and other physicians whose practices qualify as medical homes. The AMA called for those increased primary care payments to come out of areas that did not affect other specialties. However, according to Joseph Zebley III, M.D., of Baltimore, vice chair of the AAFP delegation to the AMA, "if budget-neutrality is the only way to achieve our goals on the PCMH, the AAFP will stand up for our physicians."

Meanwhile, the AAFP continued to press its message home on Capitol Hill. In early March, Epperly told Obama during a White House health care summit that family physicians were ready to do their part for health care reform, but he also pointed to the need to fix the workforce "so that all those patients have a place to go."

Less than a week later, AAFP leaders converged on Capitol Hill, meeting with multiple lawmakers and congressional staff members to talk about the importance of giving primary care and the PCMH a prominent role in health care reform initiatives.

In the meantime, the AAFP picked up a powerful ally in the form of the Medicare Payment Advisory Commission, or MedPAC, which urged Congress to revise Medicare's payment policies to better recognize and reward the provision of primary care services.

In June, the U.S. Senate turned its attention to the sustainable growth rate, or SGR, formula, which determines Medicare payments on a yearly basis. The outdated formula has led to repeated threats of substantial cuts in Medicare payments in the past. Those cuts have always been blocked by congressional action, but with the emphasis on health care reform, the Academy and other physician groups took the opportunity to point out the importance of fixing the flawed formula before any kind of health care reform could happen.

Although several bills to fix the SGR were introduced, none of them got through the legislative process, leaving physicians facing a 21 percent cut in January 2010. Once again, acting at the last minute, Congress provided a 60-day moratorium on the proposed cut, leaving Medicare payment levels at 2009 rates. Their intention is to fix the SGR with the final health care reform bill, but Medicare physicians again start another year wondering when or how much they will be paid.

The AAFP also responded positively to a CMS rule that will increase Medicare payments for primary care physicians in 2010. The agency cited new multispecialty practice expense data gathered through the Physician Practice Information Survey as its justification for the change in the payment structure, which would specifically improve payment to primary care physicians.

Meanwhile, after a summer of hearing about health care reform from constituents at town hall meetings across the nation, legislators gathered again in Washington determined to craft some sort of health care reform legislation. After much wrangling, the House passed a bill, which the AAFP announced it supported, albeit with some important qualifiers. The Academy noted that it liked the bill's proposals to reform the insurance industry, the inclusion of primary care as the foundation for reform and increased payments for primary care health professionals.

The AAFP's support of the bill, however, sparked some member protest, leading the Academy to a historical first -- a series of telephone town hall meetings where members could air their concerns and receive answers from Academy leaders regarding the AAFP's stance on health care reform. "Over the past five months or so, health care reform has been going through a lot of transformation. We've kind of gotten away from the policy stage ... into the political stage," said Epperly in the lead-in to the first call-in meeting. Along with that stage, he added, "comes a lot of anger, a lot of fear, a lot of confusion, a lot of ideology."

In particular, members were concerned that the Academy was endorsing a public plan option that was included in the House bill. AAFP leaders were swift to explain that any Academy support of a public plan option would come with a number of key caveats. If Congress decides to include a public plan option, said (then) AAFP Board Chair Jim King, M.D., of Selmer, Tenn., the AAFP would base its support decision on whether the Academy's guidelines were met.

As the year drew to a close, pressure increased on the Senate to pass its version of a health care reform bill, and political maneuvering on both sides of the aisle raised concerns about whether reforming the health care system was going to be possible. The Senate finally released a bill, with which the AAFP took immediate issue. Although the bill contained some good news for family physicians, certain parts of the legislation need to be strengthened, said Epperly, and the bill itself should include additional measures to fortify the provision of primary care services. In particular, he noted that the Senate bill did not include a fix to the SGR, leading Epperly to comment in a letter to Senate leaders that, "Continued delay only makes fixing the formula more costly."

In a much-anticipated Christmas Eve vote, the Senate passed its bill with a 60-vote majority. The two bills now await the conference process for combining them into a single bill that can pass both chambers and be signed by the president. The expectation is that a final bill will be passed and ready for the president's signature by late January or early February.

2009 also was the year when concerns about the possibility of avian influenza were replaced by very real fears of the H1N1 influenza, which reached pandemic status in June.

Word of the new virus surfaced early last year, when reports out of Mexico cited a virulent new flu with an unexpectedly high mortality rate. In April, HHS declared a public health emergency in response to the outbreak, and the World Health Organization, or WHO, raised its global influenza pandemic alert level from phase 4 to phase 5.

By May, the CDC had distributed rapid diagnostic tests to every state and had updated its guidance on the use of antiviral medications to treat and prevent H1N1 infections. The agency determined that children and adolescents were at high risk from this flu because of their limited exposure to similar viruses.

The CDC also announced that it wanted to get an early start on seasonal flu vaccinations to allow time for a vaccine against H1N1 to be developed and administered. Physicians, hospitals and public health agencies will need time to vaccinate people against both seasonal flu and the H1N1 virus, said Daniel Jernigan, M.D., M.P.H., deputy director of the CDC's Influenza Division, during a May media briefing.

By the time the WHO declared that H1N1 was officially a pandemic, the organization was reporting that there were 27,737 laboratory-confirmed cases of infection with the virus, including 141 deaths, in 74 countries.

By August, federal officials were preparing for a resurgence of the H1N1 virus in the United States. The Obama administration released $350 million in H1N1 preparedness grants to all states and territories, but the emergence of the virus underscored inherent deficiencies in the U.S. health care system. "We have a very erratic and inappropriate delivery system," said HHS Secretary Katheleen Sebelius. "H1N1 has put a spotlight on the fact that we currently don't have a system where every American has access to preventive care, doesn't have a health home and doesn't have a doctor to call."

Meanwhile, manufacturing issues slowed production of the new vaccine, pushing back expected delivery of the first doses of the vaccine until mid- to late October. The CDC's Advisory Committee on Immunization Practices, or ACIP, anticipating limited availability of the vaccine, established strict guidelines regarding which patient groups should receive the vaccine if supplies were limited. These groups included children ages 6 months to 4 years, children ages 5-18 years who have chronic medical conditions, pregnant women, and health care workers who have direct patient contact.

Finally, in mid-September, FDA officials announced that they had approved four vaccines against H1N1 and said initial lots would be distributed in early October. Because of the limited availability, however, many states chose to administer their lots of vaccine via public clinics. In other states, the vaccine was available in many of the places that deliver seasonal flu vaccine, including in physicians' offices. However, the limited availability put a strain on physicians as they grappled with figuring out who should receive what on a daily basis.

The ACIP's foresight in preparing for a potential hold-up in the release of H1N1 vaccine proved right on target when vaccine manufacturers fell woefully short of their goal of having 40 million doses of the vaccine available by the end of October. Although the U.S. government had ordered 250 million vaccine doses, during a late October media briefing, CDC Director Thomas Frieden, M.D., said that only 26.6 million doses of the vaccine were available for distribution.

Worried parents lined up at physicians' offices and public vaccination clinics across the nation. The two-dose vaccine series recommended for younger children only increased headaches for parents trying to locate vaccine. By the end of the year, however, the CDC was cautiously optimistic that new cases of the virus were beginning to taper off, although agency officials warned against a possible resurgence after the holidays. Although the pandemic has not been as bad as expected, from April to mid-November, an estimated 213,000 people were hospitalized in the United States, according to the CDC, and worldwide, more than 12,000 people died as of Dec. 27, according to the WHO.

Although H1N1 garnered most of the clinical news coverage in 2009, other issues were resolved during the course of the year. For example, at the end of 2008, shortages of the Haemophilus influenzae type b, or Hib, vaccine had led the CDC to call on physicians to defer most booster doses of the vaccine. Subsequently, re-emergence of invasive Hib disease in Minnesota was attributed to both the Hib vaccine shortage and the refusal of some parents to have their children vaccinated.

As 2009 progressed and more Hib vaccine finally became available, the CDC not only lifted the moratorium on booster doses, it asked physicians to recall patients in whom booster doses had been deferred to make sure that they received full coverage.

In other vaccine news, three federal judges ruled in three separate cases that no association between vaccines and autism exists. The decisions represent a victory for science, which has repeatedly found no link between vaccines and autism. Hopefully, the rulings will counter the "onslaught of false claims" by anti-immunization organizations, said Doug Campos-Outcalt, M.D., M.P.A., the AAFP's liaison to the ACIP. "(The judges) are basically saying (the plaintiffs' experts) are not credible, and their evidence isn't credible. They're using studies that have been discredited," he said.

In other news, the American Cancer Society, the CDC, the National Cancer Institute and the North American Association of Central Cancer Registries released a joint annual cancer report, which showed the overall incidence and death rates from cancer had decreased. The decline was attributed in large part to drops in incidence and death rates for the three most common cancers among men (lung, colorectal and prostate) and two of the three most common cancers among women (breast and colorectal).

Much furor was raised, however, when the U.S. Preventive Services Task Force, or USPSTF, released new guidelines on breast cancer screening. The new recommendations include a recommendation against routine screening mammography for women ages 40-49 who aren't at increased risk for breast cancer. In explaining the revised recommendations, task force members encouraged individualized, informed decision-making about when to start mammography screening and said the decision should take patient context into account, including the patient's values regarding benefits and harms. The USPSTF also recommended again clinicians teaching women how to perform breast self-examination, saying that self-examination does not reduce mortality.

With the focus on health care reform during 2009, health IT was identified as a cornerstone to reforming the system. The ARRA stimulus package included $19 billion for health IT, a proposal that was welcomed by many policy experts. But they cautioned that Congress needs to move ahead with health IT carefully. Funds should be used to improve the interoperability of current systems and to facilitate the ability of health care providers to share certain types of patient data, they said.

The lack of interoperability among existing systems was a recurring theme throughout 2009, as expert after expert and report after report noted that any savings in the health care system that were being attributed to the implementation of health IT would not materialize unless interoperability issues were resolved.

At the same time, health care stakeholders were scrambling to help the federal government define key health IT terms used in the ARRA, particularly the term "meaningful use" of health IT. Distribution of stimulus funds hangs on the definition of the term because health care providers must follow the government's blueprint, including meaningful use criteria, to qualify for health IT funding.

In August, Vice President Joe Biden announced that $1.2 billion would be rolled out in 2010 to help the nation's hospitals, physicians and other health care professionals purchase and use EHRs. The money is to go toward establishing the Health Information Technology Extension Program, which will allow about 70 health IT regional extension centers to offer technical assistance and guidance to support health care professionals using EHRs, and to fund the State Health Information Exchange Cooperative Agreement Program.

Then, in November, the House passed a bill that would give small and solo physician practices the ability to obtain low-cost loans to purchase health IT systems. The loans would be as much as 90 percent guaranteed and would carry a subsidized deferment period of as many as three years.

With so much resting on the definition of meaningful use, the very latest news that HHS is releasing a definition of the term is welcome, although AAFP health IT experts have yet to parse through the 600-plus pages of associated documentation.

Health care reform also focused much attention on health care workforce issues, particularly for primary care physicians. Although Congress and the Obama administration seemed to get the message that primary care needs to be the foundation of health care reform in the United States, AAFP leaders had to work hard to make the point that solving health care problems doesn't rely solely on ensuring everyone has insurance coverage. As Epperly put it repeatedly, "Without enough doctors like us practicing in the right places, Americans won't be able to access the system, no matter how extensive their coverage. It's like giving everyone a bus pass, but then providing only two buses to meet their needs."

In fact, the AAFP sounded a clarion call in its new physician workforce reform report. The Academy recommends comprehensive changes in national workforce planning, specialty distribution, graduate medical education funding and medical education policy to secure a family physician and primary care workforce that meets the country's burgeoning need.

According to Russell Robertson, M.D., chair of the Council on Graduate Medical Education, the nation's primary care physician residency programs are plagued by a lack of interest, support and funding. This situation, in turn, is helping to drive the nation's chronic shortage of primary care physicians, he said.

And, indeed, the 2009 National Resident Matching Program, known as the Match, showed another decline in 2009. The shaky economy was cited as one reason for the downward trend, as debt-burdened medical school graduates made the decision to go into more lucrative subspecialties. However, a report by the AAFP's Robert Graham Center noted that the nation's medical schools could significantly increase the number of students who choose to go into primary care by admitting students from rural and medically underserved areas and providing them with long-term experiences in primary care settings.

Another report on the outcomes of the 2009 Match found that student interest in family medicine was affected by public perception of the specialty, how family medicine practices are organized, how the specialty is treated in academia and how FPs are remunerated. Specific factors that appear to dissuade medical students from choosing family medicine, said the report, are medical school indebtedness and medical school infrastructure, including the absence of a family medicine department; a low proportion of faculty who are family physicians; and a lack of clinical clerkships in family medicine.

The lack of support for family medicine in the nation's medical schools was highlighted in 2009 when the Baylor College of Medicine/Kelsey-Seybold Clinic Family Medicine Residency Program in Houston announced it would close in 2011. In addition, the AAFP and the Massachusetts AFP were dismayed to learn that Harvard Medical School in Boston had eliminated funding for its primary care division in 2009.The action is particularly troubling because Massachusetts has a universal health insurance plan that is based on primary care, and the state has experienced a severe shortage of primary care physicians since that legislation was enacted in 2006.

On the other hand, the Duke University Family Medicine Residency in Durham, N.C., which announced it was closing in 2006 and then reopened in 2008 with a completely redesigned program, was recognized as a Level 3 Physician Practice Connections-Patient-Centered Medical Home, the National Committee for Quality Assurance's highest designation.

In addition, four new allopathic medical schools seated their first classes last fall. The founding deans and faculty in the family medicine departments of these new schools say they have initiatives that will introduce students to family medicine and primary care, teach their importance in the health care system, and boost interest in practicing in these specialties.